4 Social Phobia as a Disease We have seen in chapter 3 that social phobia can neither be characterized as an instance of a ‘‘disordered’’ anxiety nor be considered a disorder of a singular kind of anxiety. The nature of social phobia then, remains an open question. A potential answer might be found in the fact that social phobia is considered by some physicians a disease. An introduction to a series of articles published in International Clinical Pharmacology (James, 1997), for instance, had as title: ‘‘Social phobia À a debilitating disease with a new treatment option.’’ That much is also implied by the vocabulary in use. Typically, individuals seeking help are ‘‘diagnosed’’ as ‘‘suffering from’’ social phobia À ‘‘a debilitating condition with an etiology that has yet to be established.’’ Fearfulness of and an inclination toward avoidance of social occasions are said to be its ‘‘symptoms.’’ Moreover, social phobia is at least implicitly recognized as a disease by international official authorities and by some national pro- fessional bodies. Its ‘‘diagnosis’’ may be found listed in both the International Classification of Diseases (ICD-10; Classification of Mental and Behavioral Disorders) compiled by the World Health Organization (1992) as well as in the Diagnostic and Statistical Manual (DSM-IV) published by the American Psychiatric Association (APA, 1994). Is social phobia a disease then? Ostensibly, the answer is simple but as we shall see later, it is bedeviled by complex conceptual issues and the fact that there is rather little evidence to rely on. The arguments for considering social phobia a disease are mostly rhetorical and abstract, rooted in the nature of psychiatric problems in general. For this reason, I shall take a roundabout route, and before coming to a conclusion I shall examine the notion of disease and whether it is applicable to social phobia. 67 Disease or Disorder? The distinction between disease, illness and sickness is a commonplace in theoretical medicine. Disease is by definition an organic phenomenon independent of subjective experience or social conventions. It is mea- sured objectively; such measurements are the signs of disease. Illness refers to the subjective complaints communicated by the individual; these are typically known as symptoms. Sickness is the social phenome- non; it refers to the individual’s performance of various social roles and the manner of his/her participation in the life of their community (see Hofmann, 2002, pp. 652À653). In the ICD-10 and DSM-IV diagnostic manuals social phobia is found under the heading of anxiety disorders. What is a disorder? Is it a synonym of disease? In its introductory note on terminology, the ICD-10 (World Health Organization, 1992) explains: The term ‘‘disorder’’ is used throughout the classification, so as to avoid even greater problems inherent in the use of terms such as ‘‘disease’’ and ‘‘illness.’’ ‘‘Disorder is not an exact term, but it is used here to imply the existence of a clinically recognizable set of symptoms or behaviors asso- ciated in most cases with distress and with interference with personal functions.’’ (p. 5). A similar line is taken in the DSM-III and subsequent revisions. In the DSM-IV we find a caveat stating, although this manual provides a classification of mental disorders, it must be admitted that no definition adequately specifies precise boundaries for the concept of mental disorder . In DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern exhibited by an individual and that is associated with present distress (e.g. a painful symptom) or disability (i.e. impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom (p. xxi). Significantly, however, it is argued elsewhere (by some of the individuals who have been in the forefront of the creation of the DSM-III): ‘‘a mental disorder is a medical disorder whose manifesta- tions are primarily signs and symptoms of a psychological (behavioral) nature’’ (Spitzer & Endicott, 1978, p. 18). While the ICD is reticent in coming to grips with the issue and shies away from providing a definition of disease or disorder, the DSM 68 What is the Nature of Social Phobia? appears to have it both ways; it provides no real definition of disease but insinuates it is dealing with them nevertheless. It explains, all medical conditions are defined on various levels of abstraction À for example, structural pathology (e.g. ulcerative colitis), symptom presentation (e.g. migraine), deviance from a physiological norm (e.g. hypertension), and etiology (e.g. pneumococcal pneumonia). Mental disorders have also been defined by a variety of concepts (e.g. distress, dyscontrol, disadvantage, disability, inflexibil- ity, irrationality, syndromal pattern, etiology, and statistical deviation). Each is a useful indicator for a mental disorder, but none is equivalent to the concept, and different situations call for different definitions (p. xxi). A somewhat less bookish way to shed light on the concepts of disease and disorder is to look to the use of these terms in medicine. Wiggins & Schwartz (1994, p. 98) maintain that ‘‘medical doctors rarely speak of disorders; they refer instead to diseases . Physicians do employ the term disorder to express the idea that the patient has a functional rather than a structural problem.’’ What kind of functioning, however, do these authors refer to? Is it psychological and behavioral or physio- logical? The distinction is of utmost importance as the functional problem in social phobia is maladjustment to life-demands rather than a bodily one. As the final step I shall turn to pathology À the authority on disease À for its applied understanding of the terms disease and disorder. According to the Robbins Pathologic Basis of Disease, pathology is ‘‘devoted to the study of the structural and the functional changes in cells, tissues, and organs that underlie diseases’’ (Cotran, Kumar, & Robbins, 1994, p. 1). Disease, then, spans the anatomy (structure) and the physiology (function) of the human organism. In other words it is ‘‘the structural alterations induced in the cells and organs of the body (morphologic changes), and the functional consequences of the morphologic changes’’ (1994, p. 1). By ‘‘functional’’ Cotran et al. (1994) mean that ‘‘The nature of the morphological changes and their distribution in different organs or tissues influence normal function and determine the clinical features (symptoms and signs), course and prognosis of the disease’’ (p. 1). In other words, in disease functional abnormalities flow from structural changes; they are not independent of them. As functional abnormalities are the consequence of structural ones, the structural/functional perspectives on disease must not be seen either as a dichotomy or as mutually exclusive. In some circumscribed instances, however, one would be able to separate the two perspectives A Disease 69 as during the period when the structure À say of an organ À is abnormal while it is still functioning adequately. In summary, disease is viewed materialistically in terms of (observ- able) lesions to cells, tissues or organs, identifiable biochemical imbal- ances, etc. These manifest themselves through signs (e.g. fever), symptoms (e.g. expressions of suffering) or a combination of the two. These indicators are used to arrive at a tentative diagnosis. In practice, some diagnoses may never be validated independently. As a matter of principle, however, there is a concrete disease independent of its man- ifest indicators. In the absence of disease the use of the related term of diagnosis hardly makes sense. Mental Disorder À a Metaphoric Disease? For the reasons evoked above, Szasz (1987, pp. 135À169) considers the use of the term ‘‘mental illness’’ or its modern equivalent À disorder À misleading and a fallacy. In his view the use of the term ‘‘disease’’ ought to be limited to material disease only. The definition of disease by distress and maladjustment is, according to him, a metaphoric one, arrived at by analogy. The reasoning is as follows: since individuals with a bodily (i.e. material) disease suffer and may have trouble leading well-adjusted lives, those who resemble them may be deemed to be diseased as well. As one might look at disease functionally (in terms of physiology e.g. when no lesions are observed) poor psychological functioning by an inversed logic could also be conceived along the lines of a disease (disorder). According to Szasz (1987) if such patients may be said to be sick at all, it is figuratively (in terms of metaphor), as when saying ‘‘sick with love’’ to describe someone driven to distraction or ‘‘it makes me sick’’ to express disgust and disapproval. In a similar vein, Lenin, whose chief preoccupation after seizing power in October 1917 was to hold on to it, diagnosed (some) of his more upright comrades’ scruples about abandoning principle for expediency, as symptoms of left-wing communism À an infantile disease. Social Phobia À a Neurological Disease? Recent decades have been characterized by an intensification of a biologizing trend in the search for explanations of abnormality, espe- cially in US psychiatry. Consequently, some authors have come to denounce and reject the distinction made between the two kinds of disease À mental and otherwise (described above) À striving to show 70 What is the Nature of Social Phobia? that mental disorder (defined psychologically) is medical (i.e. material disease) after all. This quest À despite its modern ring À has actually a long pedigree as suggested by Griesinger’s (1845) maxim: ‘‘Geisteskrankheitn sind Gehirnkrankheitn’’ (mental diseases are diseases of the brain, quoted in Mooij, 1995). As a working hypothesis, such a possibility is eminently plausible À either for social phobia or for any other problem. Andreasen (1984, p. 29), for example asserts, ‘‘The major psychiatric illnesses are diseases. They should be considered medical illnesses just as diabetes, heart disease and cancer are.’’ On what grounds? Because The various forms of mental illness are due to many different types of brain abnormalities, including the loss of nerve cells and excesses and deficits in chem- ical transmissions between neurons; sometimes the fault may be in the pattern of the wiring or circuitry, sometimes in the command centers and sometimes in the way messages move along the wires 1984, (p. 221). To sum it up, ‘‘Mental illnesses are diseases that affect the brain, which is an organ of the body just as the heart or the stomach is. People who suffer from mental illness suffer from a sick or broken brain.’’ What evidence is there to bolster such claims? Concerning anxiety disorders as a group (social phobia is not discussed on its own), the author first expresses the hope that ‘‘anxiolytic’’ medication might shed light on the neurochemistry of anxiety. As to actual evidence, we are told that there is a possibility of a genetic component to anxiousness, that panic may be induced in certain patients with the infusion of lactate and that there is a link between panic and mitral-valve prolapse (see Andreasen, 1984, pp. 239À243). These hardly give support to the rather sweeping assertions of ‘‘brain abnormalities.’’ Sheehan (1986) advocates a broadly similar approach. Although in his book The anxiety disease social phobia is broached tangentially À as a stage in the development of what he terms the anxiety disease À his views have a bearing on our topic. ‘‘The proposed model suggests that at the center of this disease, feed- ing it like a spring, is a biological and probably a biochemical disorder’’ (p. 90). Secondary (exacerbatory) roles are accorded however to psychological (i.e. conditioning) processes and environmental stresses. In support of his construal, the author asserts that there is evidence that vulnerability to the disease may be genetically inherited, and that it is possible that such a genetic weakness could give rise to biochemical abnormal- ities . What are the precise biochemical abnormalities in this disease? No one yet knows with certainty .The best guesses so far involve certain nerve endings A Disease 71 and receptors in the central nervous system which receive and produce chemical messengers and excite the brain. These nerve endings manufacture naturally occurring stimulants called cathecolamines. It is believed that in the anxiety disease, the nerve endings are overfiring. They are working too hard, overprodu- cing these stimulants and perhaps others . At the same time there are nerve endings that have the opposite effect: they produce naturally occurring tranquil- izers, called inhibitory neurotransmitters that inhibit, calm down, and dampen the nerve firing of the brain. It appears that the neurotransmitters or the recep- tors may be deficient, either in quality or quantity . [In summary] A chain of events apparently runs from the inherited gene or genes through the cell nucleus to the cell membrane to the nerve ending and the chemicals it uses, involving some or all of the above mechanisms (Sheehan, 1986, pp. 91À92). Even without carefully examining each argument introduced by both authors conceptually and methodologically at this point (this is done in Chapter 6 critically reviewing available studies), it is clear that the insub- stantial and tangential proof provided hardly makes the case that social phobia is an instance of neurological disease. Furthermore, in a com- prehensive review of all studies having a bearing on the neurobiology of social phobia, Nickell & Uhde (1995, p.128) conclude that: ‘‘what avail- able data have been collected across different laboratories suggest that tests of biological function in patients with social phobia are more typ- ically similar to, rather than different from, those of normal control subjects.’’ A more recent review (Dewar & Stravynski, 2001) concurred. Despite continuing attempts À all based on the general notion that a difference between social phobic and matched control subjects on some neurobiological parameter would reveal an abnormality À the hypothet- ical biological substrate of social phobia, fails to materialize. The implications of this are far reaching. Either the paradigm and methodologies used in this research program are inadequate and need to be radically rethought, or there is no neurobiological deficit or excess underlying social phobia to be found. In the words of Nickell & Uhde, (1995): ‘‘While this continuum view of social anxiety to social phobia might appear self-evident in some scientific circles, it is, in truth, a different theoretical construct from the disease model’’(p. 128). The Social Context of the Disease Model The use of the term disease in reference to social phobia occurs mostly in publications describing and (wittingly or not) promoting the use of psychotropic medication as a treatment. It is disconnected from its scientific basis and used rhetorically, implying that in the face of disease only medication will do. 72 What is the Nature of Social Phobia? Clinicians, tell patients that they suffer from a chemical imbalance in the brain. The expla- natory power of this statement is about of the same order as if you said to the patient ‘‘you are alive’’. It confuses the distinction between etiology and corre- lation, and cause and mechanism, a common confusion in our field. It gives the patient a misleading impression that his or her imbalance is the cause of his or her illness, that it needs to be fixed by purely chemical means, that psychother- apy is useless and that personal efforts and responsibility have no part to play in getting better (Lipowski, 1989, p. 252). Thus the notion of disease complements the designation of certain compounds (which have many other applications) as indicated for social phobia. These are typically elements in marketing campaigns orches- trated by pharmaceutical companies. Pharmaceutical Marketing, a trade publication, ‘‘singled out social phobia as a positive example of drug marketers’ shaping medical and public opinion about a disease’’ (Moynihan, Heath, & Henry, 2002, p. 888). Is Social Phobia a Disease? Ultimately, it is a matter of definition. The possibilities are as follows: most physicians, when they give the matter any thought at all, believe that dis- ease is a scientific term whose sphere of application should be determined by doctors on technical or scientific grounds, but that in practice, they apply the term inconsistently, often in response to what are quite clearly social or political considerations of various kinds. What should the architects of a classification of diseases or a classification of psychiatric disorders do in this unsatisfactory and confusing situation? A total of four alternative strategies are available. The first, adopted by the World Health Organization, is to ignore the problem, perhaps in the hope that others will do the same, and to make no attempt to define the term disease or any of its analogues. The second, adopted by the task force respon- sible for DSM-III, is to provide a definition, which is vaguely worded to allow any term with medical connotations to be either included or excluded in con- formity with contemporary medical opinion. (A subsidiary strategy, adopted by both WHO and the APA, is to refer throughout to mental disorders rather than diseases, on the assumption that the undefined term disorder will be both less contentious and broader in scope than the similarly undefined term disease.) The third strategy, which so far as I am aware has never yet been adopted, at least for a psychiatric classification, is to provide an operational definition of disease (or disorder), which provides unambiguous rules of application, and then abide by the unsatisfactory constraints imposed by that definition. The fourth is to concede openly that psychiatric classifications are not classifications of diseases or disorders, but simply of the problems psychiatrists are currently consulted about, and that the justification for including such categories as oppositional disorder or pyromania (DSM-III) or specific reading retardation A Disease 73 (ICD-9) is merely that in practice psychiatrists are consulted by, or about, people with such problems. My own view is that this is probably the best course, at least until we have resolved some of the problems discussed above. It avoids the ambiguity and intellectual dishonesty of the first two options and the serious constraints of the third. It does, of course, leave unresolved the question of which of the conditions listed in the glossary is a disease and which merely a problem result- ing in a psychiatric consultation, but the use of the term ‘‘mental disorder’’ does that anyway (Kendell, 1986, pp. 41À42). In the final analysis, if disease is an organic problem, scientifically demonstrated, social phobia is not a disease. If disease is any problem attended to by a physician, social phobia may be considered one. 74 What is the Nature of Social Phobia? . 4 Social Phobia as a Disease We have seen in chapter 3 that social phobia can neither be characterized as an instance of a ‘‘disordered’’ anxiety. as well as in the Diagnostic and Statistical Manual (DSM-IV) published by the American Psychiatric Association (APA, 1994). Is social phobia a disease then?